commissioning, funding and service development
how do we pay for quality services in the 21st
century?

Dr Deuchar reminded us of
the strategic background and the constantly changing agenda in
healthcare delivery. He described some of the important
developments such as appointment of GP mental health leads and the
lack of implementation of the public mental health agenda.

He described the wider
issues of sustainability, variability, waste and values. Focusing
on the concept of values based commissioning which extrapolates
value-based practice into the commissioning environment. This
approach gives the perspective of patients and carers equal footing
to professional perspectives at each stage of the commissioning
cycle. Values such as reciprocity (mutual learning), peer working
and the lived experience are emphasised. The Joint Commissioning
Panel (JCP) made up of the RCGP, RCPsych, national user
organisations and others was formed in 2010. They have produced a
series of commissioning guides each one focused on a different
strategic area e.g. dementia, children and young people, forensic
services etc. I have included the web address for the JCP where the
published guides can be downloaded.

In future services will
need to integrate patients and families, whole personal care and
collaboration between primary and secondary care, seamless
commissioning with both physical and social care.

Dr Deuchar brought
information about the Strategic Clinical Networks (SCNs) and the
College Commissioning Centre – for psychiatrists who wish to get
more involved – see website links.

Lecture 2: Commissioning: The
Role of the Local Psychiatrist: Dr Laurence Mynors-Wallis,
Registrar of RCPsych, Medical Director of Dorset HealthCare NHS
Foundation Trust

Dr Mynors-Wallis
concentrated his lecture on how psychiatrists can influence local
commissioning decisions. Even though the government has said there
should be parity we are still seeing inequity in the way
commissioners fund services. There are local groupings such as the
Clinical Senates and SCNs but they have not yet had a major
impact.

So how can psychiatrists influence commissioning? Dr Mynors-Wallis
suggested that they can start by getting to know local GPs and
concentrate on understanding what GPs want. He suggested that this
influence would best be exerted through personal contact, informal
networks and generating positive perceptions and anecdotes.

He advocated that we find
out what local GPs want and they generally want:

Coherent arrangements at
the margins of the working day and out of hours

Sharing of clinical
risk

Dr Mynors-Wallis reminded
us that in the ever changing personnel in the management structures
of the trust the two constants were the patients and often the
senior doctors, we were often a major source of continuity. He
proposed that doctors should get involved in restructuring even
though it can be a difficult process, that doctors should be active
in advising the board in a clear and co-ordinated way.

In conclusion get to know
local structures in the CCG, GPs, public health and actively work
together as a medical group.

Parallel sessions

Parallel session 1: Getting
ready to improve: an introduction to the ‘Model for Improvement’
Maureen McGeorge, Project Manager with the Patients
Association

Information from speaker
- this session will guide take you on a whistle-stop tour of the
Institute for Healthcare Improvement’s ‘Model for Improvement’,
stopping off en route to allow you to hear about the experiences of
some mental health service teams that have tried using it. We
will conclude the session by allowing you to apply the learning to
planning a simple improvement project that you can take away with
you.

The process is decided
locally and money should be allocated on the basis of need with a
clear end-point when the budget is signed off. A review of the
national pilot found that the condition itself didn’t improve but
quality of life improved, there was a reduction in unplanned care
and the budgets were cost effective. Most people valued services
and bought in additional services such as psychology and others
reduced traditional services choosing to use their money to attend
college or improve social inclusion.

Information from speaker
- this session will explore the potential role for psychiatrists in
the business element of retaining and winning services, illustrated
through the experiences of a doctor working for one of the main
providers of addiction treatment services in England and Wales

Parallel session 4: Approaching
service development through the application of service logic, Dr
Mark Spurrell, Consultant Psychiatrist at Calderstones NHS
Partnership Trust

Dr Spurrell suggested
that we had a long tradition of patient centred care and that we
should be looking at emerging ideas such as value driven healthcare
(Porter) and service dominant logic (Vargo and Lusch). He described
value driven health care as one where the patient is a customer and
the focus is on outcomes such as functional improvement and cycle
time. Service dominant logic is based on the idea that service is
the application of logic and skills for a benefit and so service is
part of an exchange. He emphasised the ideas of co-production and
co-creation with customers or patients making choices.

He went on to discuss the
different types of market, are we selling to the customer (patient)
or another business (B2B marketing). He described a piece of work
he had undertaken to apply these concepts to the CPA process. He
concluded that trusts are brokers or a confederation and suggested
they needed a shared platform with commissioners and an overarching
framework.

The NHS spends £14
billion treating mental health but needs another £14 billion to
treat unmet needs. The centre for mental health carried out a
systematic review of 100 strategies and interviewed members of ten
health and wellbeing boards to find out how far they have included
mental health issues as a priority and what they have focused
upon.

Health and wellbeing
boards bring together local authorities and health and care system
leaders to improve the health and wellbeing of their local
populations. They are tasked with identifying key health needs in
their area through a joint strategic needs assessment and then set
priorities through a strategy.

The review found 9/10
aimed to tackle at least 1 mental health issues, 55% prioritised
children's mental health and 46% prioritised better access to
services. They recommended that mental health organisations should
concentrate on influencing those strategy priorities intimately
connected with mental health, but where the link with mental health
has not been made such as alcohol, smoking and obesity.

Mr Bell also recommended
supporting mental health champions (they sit on the health and
wellbeing boards after being appointed by local councils) as they
can raise the profile of mental health and offer expertise on
implementation of priorities.

He spoke of the key
features of recovery oriented services - bigger role for peer
support, co-production, recovery colleges, safer inpatient wards
(no force first), help with employment needs, housing, other basic
needs, support for family and friends.

Mr Bell emphasised the
importance of welfare advice in mental health services as 83% of
people using mental health services have welfare rights issues. He
gave the example of Sheffield CAB paid for by the mental health
trust in 1976. If they were able to shorten an inpatient stay by
even 1 day the trust saved over £300. He suggested that all
secondary services should offer consistent access to welfare
advise, to offer it early, embed it in the recovery model and that
they assess welfare needs.

Lecture 4:
Quality and Service Improvement: What Healthcare has been learning
from other Sectors: Dr Nathan Proudlove, Senior Lecturer,
Operational Research at Manchester Business School, University of
Manchester

Dr Proudlove started by describing how the service
improvement model known as LEAN was developed by W Edwards Demming
an American statistician. This work started in the car industry and
was imported to healthcare in the 1980s. He described several other
models.

He suggested that we started by developing our own measurements of
change or metrics – how will we know that a change is an
improvement? The next step was to test ideas before implementing
changes by experimenting and suggested using the PDSA (plan, do,
study, act cycle) cycle. He suggested using PDSA in small cycles,
failing early, small and often.

Dr Proudlove recommended finding clinically meaningful data that
was based on local performance measures, using visually presented
data that could at a glance show any changes occurring. He proposed
that often data was already being collected but not being used or
examined in a useful way. He recommended the work of Simon Dodds
(software developed).

Other approaches described included the fishbone diagram which
supported a structured brainstorming process and the search for
potential causes. Using the 5 Whys to get to the root cause. The 80
20 rule - 20% of variable causes 80% of problems. Pathway mapping
using post-it notes to understand the flow and what needs to be
done.

Dr Proudlove gave us a detailed description of classic LEAN
describing the seven wastes in healthcare (transport, inventory,
motion, waiting, over production, over burden, defects), looking at
the flow with the push (own pace) and pull (customer demand) and
the use of visual management for project management. He described
several examples within healthcare such as Salford Royal and Tees,
Esk and Wear Trust that had adopted the use of LEAN in a
significant way with its use being driven by the board.

He concluded that as
clinicians we should start small with issues that niggled at
us.